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  1. Healthcare-associated infections: a national patient safety problem and the coordinated response. | PSNet

    psnet.ahrq.gov/issue/healthcare-associated-infections-national-patient-safety-problem-and-coordinated-response
    May 20, 2016 - Commentary Healthcare-associated infections: a national patient safety problem and the coordinated response. Citation Text: Jeeva RR, Wright D. Healthcare-associated infections: a national patient safety problem and the coordinated response. Med Care. 2014;52(2 Suppl 1):S4-8. doi:10.109…

  2. Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient. | PSNet

    psnet.ahrq.gov/issue/failure-rescue-following-emergency-surgery-fram-analysis-management-deteriorating-patient
    May 19, 2021 - Study Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient. Citation Text: Sujan M, Bilbro N, Ross A, et al. Failure to rescue following emergency surgery: A FRAM analysis of the management of the deteriorating patient. Appl Ergon.…

  3. Medication-administration errors in an urban mental health hospital: a direct observation study. | PSNet

    psnet.ahrq.gov/issue/medication-administration-errors-urban-mental-health-hospital-direct-observation-study
    September 03, 2014 - Study Medication-administration errors in an urban mental health hospital: a direct observation study. Citation Text: Cottney A, Innes J. Medication-administration errors in an urban mental health hospital: a direct observation study. Int J Ment Health Nurs. 2015;24(1):65-74. doi:10.1111…

  4. Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. | PSNet

    psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative-study
    September 09, 2015 - Study Classic Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. Citation Text: Johnston MJ, Arora S, King D, et al. Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. Surgery.…

  5. Characteristics of critical incident reporting systems in primary care: an international survey. | PSNet

    psnet.ahrq.gov/issue/characteristics-critical-incident-reporting-systems-primary-care-international-survey
    September 07, 2022 - Study Characteristics of critical incident reporting systems in primary care: an international survey. Citation Text: Höcherl A, Lüttel D, Schütze D, et al. Characteristics of critical incident reporting systems in primary care: an international survey. J Patient Saf. 2022;18(1):e85-e91.…

  6. Prevalence and predictors of adverse events in older surgical patients: impact of the present on admission indicator. | PSNet

    psnet.ahrq.gov/issue/prevalence-and-predictors-adverse-events-older-surgical-patients-impact-present-admission
    October 04, 2023 - Study Prevalence and predictors of adverse events in older surgical patients: impact of the present on admission indicator. Citation Text: Kim H, Capezuti E, Kovner C, et al. Prevalence and predictors of adverse events in older surgical patients: impact of the present on admission indi…

  7. Factors influencing family member perspectives on safety in the intensive care unit: a systematic review. | PSNet

    psnet.ahrq.gov/issue/factors-influencing-family-member-perspectives-safety-intensive-care-unit-systematic-review
    July 21, 2021 - Review Factors influencing family member perspectives on safety in the intensive care unit: a systematic review. Citation Text: Coombs MA, Statton S, Endacott CV, et al. Factors influencing family member perspectives on safety in the intensive care unit: a systematic review. Int J Qual H…

  8. Medication errors in community pharmacies: evaluation of a standardized safety program. | PSNet

    psnet.ahrq.gov/issue/medication-errors-community-pharmacies-evaluation-standardized-safety-program
    June 29, 2022 - Study Medication errors in community pharmacies: evaluation of a standardized safety program. Citation Text: Ledlie S, Gomes T, Dolovich L, et al. Medication errors in community pharmacies: evaluation of a standardized safety program. Explor Res Clin Soc Pharm. 2023;9:100218. doi:10.1016…

  9. Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety. | PSNet

    psnet.ahrq.gov/issue/using-enhanced-oral-chemotherapy-computerized-provider-order-entry-system-reduce-prescribing
    October 20, 2014 - Study Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety. Citation Text: Collins CM, Elsaid KA. Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve …

  10. Improved medication management with introduction of a perioperative and prescribing pharmacist service. | PSNet

    psnet.ahrq.gov/issue/improved-medication-management-introduction-perioperative-and-prescribing-pharmacist-service
    August 05, 2020 - Study Improved medication management with introduction of a perioperative and prescribing pharmacist service. Citation Text: Nguyen AD, Lam A, Banakh I, et al. Improved medication management with introduction of a perioperative and prescribing pharmacist service. J Pharm Pract. 2020;33(3…

  11. The impact of critical incidents on nurses and midwives: a systematic review. | PSNet

    psnet.ahrq.gov/issue/impact-critical-incidents-nurses-and-midwives-systematic-review
    May 11, 2022 - Review The impact of critical incidents on nurses and midwives: a systematic review. Citation Text: Buhlmann M, Ewens B, Rashidi A. The impact of critical incidents on nurses and midwives: A systematic review. J Clin Nurs. 2020;30(9-10):1195-1205. doi:10.1111/jocn.15608. Copy Citation …

  12. Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults. | PSNet

    psnet.ahrq.gov/issue/optimizing-post-acute-care-patient-safety-scoping-review-multifactorial-fall-prevention
    January 12, 2022 - Review Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults. Citation Text: Leland NE, Lekovitch C, Martínez J, et al. Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention int…

  13. Bridging the gap between hospital and primary care: the pharmacist home visit. | PSNet

    psnet.ahrq.gov/issue/bridging-gap-between-hospital-and-primary-care-pharmacist-home-visit
    April 10, 2019 - Commentary Bridging the gap between hospital and primary care: the pharmacist home visit. Citation Text: Ensing HT, Koster ES, Stuijt CCM, et al. Bridging the gap between hospital and primary care: the pharmacist home visit. Int J Clin Pharm. 2015;37(3):430-4. doi:10.1007/s11096-015-0093…

  14. Social disparities in patient safety in primary care: a systematic review. | PSNet

    psnet.ahrq.gov/issue/social-disparities-patient-safety-primary-care-systematic-review
    January 08, 2025 - Review Emerging Classic Social disparities in patient safety in primary care: a systematic review. Citation Text: Piccardi C, Detollenaere J, Bussche PV, et al. Social disparities in patient safety in primary care: a systematic review. Int J Equity Health. 2018;…

  15. RISE: exploring volunteer retention and sustainability of a second victim support program. | PSNet

    psnet.ahrq.gov/issue/rise-exploring-volunteer-retention-and-sustainability-second-victim-support-program
    April 21, 2021 - Study RISE: exploring volunteer retention and sustainability of a second victim support program. Citation Text: Connors C, Dukhanin V, Norvell M, et al. RISE: Exploring Volunteer Retention and Sustainability of a Second Victim Support Program. J Healthc Manag. 2021;66(1):19-32. doi:10.10…

  16. A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. | PSNet

    psnet.ahrq.gov/issue/prospective-study-paediatric-cardiac-surgical-microsystems-assessing-relationships-between
    February 14, 2024 - Study A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. Citation Text: Schraagen JM, Schouten T, Smit M, et al. A prospective study of paediatric cardiac surgical microsystems: assessi…

  17. Why and how to approach user experience in safety-critical domains: the example of health care. | PSNet

    psnet.ahrq.gov/issue/why-and-how-approach-user-experience-safety-critical-domains-example-health-care
    May 05, 2021 - Commentary Why and how to approach user experience in safety-critical domains: the example of health care. Citation Text: Grundgeiger T, Hurtienne J, Happel O. Why and how to approach user experience in safety-critical domains: the example of health care. Hum Factors. 2020;63(5):821-832.…

  18. Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting. | PSNet

    psnet.ahrq.gov/issue/fix-and-forget-or-fix-and-report-qualitative-study-tensions-front-line-incident-reporting
    May 18, 2016 - Study Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting. Citation Text: Hewitt TA, Chreim S. Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting. BMJ Qual Saf. 2015;24(5):303-10.…

  19. Surgeon burnout, impact on patient safety and professionalism: a systematic review and meta-analysis. | PSNet

    psnet.ahrq.gov/issue/surgeon-burnout-impact-patient-safety-and-professionalism-systematic-review-and-meta-analysis
    October 14, 2020 - Review Surgeon burnout, impact on patient safety and professionalism: a systematic review and meta-analysis. Citation Text: Al-Ghunaim TA, Johnson J, Biyani CS, et al. Surgeon burnout, impact on patient safety and professionalism: A systematic review and meta-analysis. Am J Surg. 2022;22…

  20. Prevalence, types, and sources of bullying reported by US general surgery residents in 2019. | PSNet

    psnet.ahrq.gov/issue/prevalence-types-and-sources-bullying-reported-us-general-surgery-residents-2019
    May 06, 2020 - Study Prevalence, types, and sources of bullying reported by US general surgery residents in 2019. Citation Text: Zhang LM, Ellis RJ, Ma M, et al. Prevalence, types, and sources of bullying reported by US general surgery residents in 2019. JAMA. 2020;323(20):2093-2095. doi:10.1001/jama.2…
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